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. 2001 Jul-Aug;8(4):379-90.
doi: 10.1136/jamia.2001.0080379.

Derivation and evaluation of a document-naming nomenclature

S H Brown  1 , M Lincoln, S Hardenbrook, O N Petukhova, S T Rosenbloom, P Carpenter, P Elkin
Affiliations

Derivation and evaluation of a document-naming nomenclature

S H Brown et al. J Am Med Inform Assoc. 2001 Jul-Aug.

Abstract

Objective: The Computerized Patient Record System is deployed at all 173 Veterans Affairs (VA) medical centers. Providers access clinical notes in the system from a note title menu. Following its implementation at the Nashville VA Medical Center, users expressed dissatisfaction with the time required find notes among hundreds of irregularly structured titles. The authors' objective was to develop a document-naming nomenclature (DNN) that creates informative, structured note titles that improve information access.

Design: One thousand ninety-four unique note titles from two VA medical centers were reviewed. A note-naming nomenclature and compositional syntax were derived. Compositional order was determined by user preference survey.

Measurements: The DNN was evaluated by modeling note titles from the Salt Lake City VA Medical Center (n=877), Vanderbilt University Medical Center (n=554), and the Mayo Clinic (n=42). A preliminary usability evaluation was conducted on a structured title display and sorting application.

Results: Classes of note title components were found by inspection. Components describe characteristics of the author, the health care event, and the organizational unit providing care. Terms were taken from VA medical center information systems and national standards. The DNN model accurately described 97 to 99 percent of note titles from the test sites. The DNN term coverage varied, depending on component and site. Users found the DNN title format useful and the DNN-based title sorting and note review application easy to learn and quick to use.

Conclusion: The DNN accurately models note titles at five medical centers. Preliminary usability data indicate that DNN integration with title parsing and sorting software enhances information access.

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Figures

Appendix
Appendix
Usability Evaluation
Figure 1
Figure 1
Note titles in the Computerized Patient Record System at the Nashville Veterans Affairs Medical Center, before implementation of the document-naming nomenclature.
Figure 2
Figure 2
User preference survey for note title format.
Figure 3
Figure 3
Title parsing and sorting application used in usability evaluation.
See this image and copyright information in PMC

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